A patient who was in a fight sustained several direct blows to the face. The nurse assesses an elevated pulse (P 108), elevated respiratory rate (RR 24), and obvious deformity to the right side of the face

Question

What should the nurse identify as the priority of care for this patient?
1. frequently assessing the blood pressure for signs of shock and initiating IV fluids
2. monitoring the elevated respiratory rate and maintaining the airway
3. monitoring the elevated pulse rate and looking for signs of pallor
4. frequently assessing for facial pain and administering pain medication p.r.n.

Answer 1

Correct Answer: 2

With facial fractures, the potential risk for airway compromise must be considered. The nurse helps the patient clear secretions from the oropharynx and reports elevated respiratory rate (tachypnea) to the physician. Although IV fluids may be initiated, the patient's assessment does not reflect a significant risk for shock. The injuries will cause bruising and discoloration, not pallor. While the patient will require ongoing pain assessment and management, this is not the most important nursing action.